Complications
Pancreatitis following ERCP is the most common complication of the procedure, occurring in 3.5% of patients.[123] It is associated with female sex, age <65 years, a longer biliary cannulation time, and precut-sphincterotomy.[124] It is usually managed with analgesia, intravenous hydration, and nutritional support. Indomethacin rectal suppository, given immediately after the ERCP, can help prevent this complication.[97][123][125]
Bile duct injury is defined as any damage to the bile duct, including leakage of bile, iatrogenic bile duct injury, and biliary strictures. Bile leak occurs in 0.5% to 1.5% of patients undergoing laparoscopic cholecystectomy, and is associated with significant morbidity and higher 1-2 year mortality compared with patients who have uncomplicated surgery.[1][135][136]
Bile duct injuries occur in 0.4% to 1.5% of patients undergoing cholecystectomy and are due to direct surgical trauma or from partial/complete transection of the bile duct due to clips or ligation.[136] In the short term (acute or the perioperative state), bile duct injuries can lead to bleeding or perforation and biliary obstruction. More long term, bile duct strictures can develop. Biliary strictures are generally preventable. Diagnosis is with laboratory tests (elevated white cell count, bilirubin, liver enzymes) and imaging (contrast computed tomography or magnetic resonance cholangiopancreatography), and patients can develop persistent pain, fever, nausea, and vomiting post cholecystectomy.[1]
Risk factors for bile duct injury are Mirizzi syndrome, impacted cystic duct stones, and abnormal anatomy.[1] If detected intraoperatively, primary surgical repair can be performed; otherwise bile duct injuries are usually managed with endoscopic transpapillary biliary stent insertion, unless there has been complete transection.[1] If there is a concomitant biloma (a collection of bile outside of the biliary tree), percutaneous drainage may also be necessary and antibiotics should be started immediately.[136]
The frequency of bleeding as a complication of ERCP with sphincterotomy and stone extraction varies from 1% to 48% depending on what definition is applied, such as the magnitude of bleeding (limited vs. life-threatening), and if it occurred during the procedure.[137]
Risk factors for post-sphincterotomy bleeding include a stone impaction at the ampulla, bleeding during initial sphincterotomy, cholangitis prior to ERCP, deranged coagulation, and recent hemodialysis.[138][139] This complication is commonly recognized at the time of the procedure and can be treated with endoscopic hemostatic techniques, such as injection of epinephrine.[138]
If a gallstone erodes through the gallbladder wall, a cholecystoenteric fistula can develop and lead to gastric outlet obstruction, known as Bouveret syndrome. This usually presents with nausea, vomiting, and abdominal pain, although it can present with symptoms of upper gastrointestinal bleeding, such as hematemesis or melena.[133]
Diagnosis is made on abdominal x-ray demonstrating gastrointestinal tract obstruction, ultrasound, or computed tomography or magnetic resonance imaging.[133] Treatment to relieve the obstruction commonly entails endoscopic extraction of the stone with placement of a temporary biliary stent, or surgery with common bile duct exploration to close the fistula. Cholecystectomy is usually then warranted to prevent stone recurrence.[133][134]
If a stone erodes through the gallbladder wall and creates a cholecystoenteric fistula, the stone can then pass into, and lead to obstruction of, the narrowest segment of healthy bowel, often the terminal ileum.[32] This presents with symptoms of bowel obstruction (nausea, vomiting, crampy abdominal pain, distension).[32] Computed tomography is the most accurate imaging modality to confirm the diagnosis; treatment is usually with surgery.[32]
Acute cholecystitis occurs when obstruction of the cystic duct leads to gallbladder inflammation. Patients usually have intense, steady right upper quadrant pain (sometimes radiating to the back, right shoulder, or chest), a positive Murphy's sign, fever, nausea, vomiting, and leukocytosis.[1]
Diagnosis can be made on abdominal ultrasound (demonstrating gallbladder stones, with either a sonographic Murphy's sign or thickened gallbladder).[1] Computed tomography (CT) can accurately demonstrate gallbladder distention and thickening, as well as complications such as fistulae, gallbladder wall emphysema, and perforation.[1] Cholescintigraphy (hepatobiliary iminodiacetic acid [HIDA] scan) demonstrating absence of gallbladder filling is over 90% accurate, although false positives can occur in fasting and intensive care unit patients.[1][126][127] HIDA scans are only performed if ultrasound and CT are not diagnostic, as the lack of gallstone visualization and ionizing radiation make this test less favorable.[1]
Treatment involves intravenous hydration, antibiotics, analgesia as needed, and early cholecystectomy. Evidence suggests that early cholecystectomy is associated with shorter hospital stay and fewer recurrent symptoms.[128] Patients unsuitable for surgery can be managed with percutaneous cholecystostomy tube placement.[1]
Acute cholangitis occurs when there is complete obstruction of the bile duct resulting in cholestasis and infected bile. The classic presentation is biliary pain, jaundice, and fever (Charcot triad).[1] Hypotension and altered mental status may also be present (Reynolds pentad). Leukocytosis and abnormal liver function tests are typical.[1] Bacterial cholangitis should be considered a medical emergency.
Treatment involves intravenous hydration, broad-spectrum antibiotics, analgesia, and biliary decompression within 24-48 hours.[1] The preferred method of biliary decompression is ERCP with sphincterotomy and stone extraction.[129] Biliary stent placement without stone removal, percutaneous drainage, or surgical common bile duct exploration are alternative options if endoscopic decompression fails or if there are contraindications to endoscopic procedures, such as coagulopathy.[1][31][130] If ERCP fails, endoscopic ultrasound-guided biliary drainage, percutaneous drainage, or surgical common bile duct exploration may become necessary.[131]
Occurs when there is pancreatic outflow obstruction or reflux of bile into the pancreatic duct. Patients usually present with severe epigastric abdominal pain with or without radiation into the back, nausea and vomiting, and elevated pancreatic enzymes.[1]
Diagnosis is confirmed on ultrasound, which demonstrates common bile duct dilation, although it is less accurate for detecting gallstones.[1]
Treatment involves aggressive intravenous hydration, analgesia, and consideration of ERCP with sphincterotomy and stone extraction within 72 hours of admission (for severe acute pancreatitis with evidence of biliary obstruction and/or cholangitis).[20][31][132] Mild acute pancreatitis requires only fluids and supportive care.
Cholecystectomy should be offered before discharge from the hospital.
Mirizzi syndrome is when a large gallstone becomes lodged in the cystic duct and compresses or causes inflammation of the common hepatic duct, resulting in biliary obstruction and jaundice.[31] It is an uncommon complication of cholelithiasis, occurring in 0.18% to 0.35% of patients with cholecystectomy in the US.[31] There are several subtypes of the syndrome, classified by the amount of involved duct and presence/absence of a fistula.[31] Mirizzi syndrome is typically treated with laparoscopic cholecystectomy, although the open procedure is preferred for certain subtypes.[1][31]
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